Correlates of hepatitis B testing in Ghana: The role of knowledge, stigma endorsement and knowing someone with hepatitis B

Abstract Hepatitis B testing is the gateway for prevention and care. However, previous studies document low hepatitis B testing uptake in sub‐Saharan Africa. This study investigated knowledge, stigma endorsement and knowing someone with hepatitis B as correlates of hepatitis B testing behaviours among people in the Greater Accra and Northern regions of Ghana. A cross‐sectional survey was completed by 971 participants (Greater Accra = 503, and Northern region = 468) between October 2018 and January 2019. Approximately 54% of the participants reported having been tested for hepatitis B. The logistic regression analyses showed that having greater hepatitis B knowledge was positively associated with hepatitis B testing (OR = 1.22, 95% CI: 1.14–1.30). Higher hepatitis B stigma endorsement was negatively related to hepatitis B testing (OR = 0.97, 95% CI: 0.96–0.99). Also, participants who knew someone (i.e. parent, sibling and/or friend) with hepatitis B were more likely to have tested compared to those who did not know someone with hepatitis B (OR = 7.15, 95% CI: 5.04–10.14). This study demonstrates that knowing someone with hepatitis B increases the likelihood of testing, highlighting the need to create safe and non‐judgmental contexts for people with hepatitis B (PWHB) to disclose if they want to. Also, given that greater hepatitis B knowledge increases testing and hepatitis B stigma endorsement impedes testing, interventions that increase knowledge and reduce stigma should be incorporated in efforts to promote testing in Ghana.


| INTRODUC TI ON
Hepatitis B viral (HBV) infection remains a significant public health threat worldwide. Globally, about 257 million people are chronically infected with hepatitis B, and 887,000 deaths occur annually due to hepatitis B-related complications (World Health Organization [WHO], 2019). Africa is disproportionately affected by hepatitis B (Béguelin et al., 2018;Breakwell et al., 2017;McNaughton et al., 2020;Lemoine & Thursz, 2017;Spearman et al., 2017) with a prevalence estimate of 8.83% compared to 5.26% in the Western Pacific region, and Scaling up hepatitis B testing, and diagnosis is an effective response to the burden of hepatitis B Spearman et al., 2017;WHO, 2017b;WHO, 2018). Hepatitis B testing can break the disease transmission cycle (Cochrane et al., 2016;Spearman et al., 2017;WHO, 2017b). It can lead to the early identification of PWHB (Easterbrook et al., 2017), and subsequently link them to care and treatment (Lemoine et al., 2015). Hepatitis B testing also provides an opportunity to link people to interventions that can reduce transmission, including counselling on risk behaviours, the supply of prevention commodities (e.g. sterile needles and syringes) and vaccination (WHO, 2017b). However, in sub-Saharan Africa (SSA), less than 1% of PWHB are aware of their hepatitis B status (Béguelin et al., 2018). As such, the optimal benefit of hepatitis B testing is yet to be achieved by SSA (Anfaara et al., 2018;Béguelin et al., 2018). Therefore, it is crucial to better understand what makes people get tested for hepatitis B.
In countries other than Ghana, research has identified several psychosocial factors that compromise access to hepatitis B testing (Lemoine et al., 2015;Li et al., 2012;World Hepatitis Alliance, 2018).
These include fear of a positive diagnosis, stigma and inadequate knowledge about hepatitis B (Hamdiui et al., 2018;Li et al., 2017;WHO, 2017b;World Hepatitis Alliance, 2018). Regarding hepatitis B knowledge, previous studies have established a gap among different sub-populations in Ghana (Abdulai et al., 2016;Adjei et al., 2018;Adoba et al., 2015;Kwadzokpui et al., 2020). For example, a study conducted among barbers in the Obuasi municipality of Ghana found that nearly two-thirds (64.5%) of the participants were unaware of the modes of transmission for hepatitis B (Adoba et al., 2015).
Similarly, in a study done in Brong Ahafo region of Ghana, more than half (59%) of the pregnant women included did not know that hepatitis B can be prevented through vaccination (Adjei et al., 2018). What has not yet been investigated in Ghana is the relationship between hepatitis B knowledge and testing. However, evidence from other locales (e.g. Canada and the United States) indicate that higher hepatitis B knowledge is associated with an increase in the uptake of hepatitis B testing (Calderon et al., 2014;Li et al., 2012).
Another factor that has been found to influence hepatitis B testing is stigma (Cochrane et al., 2016;Franklin et al., 2018;Freeland et al., 2020;Hara et al., 2018;Li et al., 2012;Smith-Palmer et al., 2020). For example, among African migrants in the United States, fear of being stigmatised was negatively related to testing uptake (Sriphanlop et al., 2014).
Similarly, more stigma was associated with a decrease in hepatitis B testing among Chinese migrants in a study done in Canada (Li et al., 2012).
However, it remains unclear whether these findings also generalise to a Ghanaian context given the cultural differences. Although hepatitis B stigmatisation has been reported in Northern and Southern Ghana (Adjei et al., 2017(Adjei et al., , 2019, the relationship between hepatitis B stigma and testing has not previously been investigated in the Ghanaian context. Further, an awareness of PWHB's sero-status among close family contacts has been identified as an important predictor for hepatitis B testing in some countries including Zambia (Franklin et al., 2018), Canada (Li et al., 2012) and USA (Cheng et al., 2017). However, its role in hepatitis B testing is not known in the Ghanaian context.
To date, the only study that has examined hepatitis B testing in Ghana looked at health facilities as a contextual factor but did not explore individual factors related to hepatitis B testing (Anfaara et al., 2018). In order to better understand the determinants of hepatitis B testing in Ghana, we investigated hepatitis B knowledge, hepatitis B stigma endorsement and knowing someone with hepatitis B as correlates of testing for hepatitis B among Ghanaians.

| THEORE TI C AL PER S PEC TIVE
The theoretical perspective adopted in this study was the behavioural model of health service utilisation (Andersen, 1995). According to the model, utilisation of health services is a function of an individual's predisposition to use a service, enabling or impeding factors and the need for care (Andersen, 1995). Predisposing factors are the characteristics of a person including demographic variables. Enabling and impeding factors are factors capable of either enhancing or inhibiting an individual's use of healthcare services. Lastly, need factors are the immediate triggers to healthcare service utilisation by an individual (Andersen, 1995). Several studies have adopted and applied the behavioural model of health service utilisation to understand different aspects of health service use (Azfredrick, 2016;Li et al., 2016;Tolera et al., 2020) including the uptake of breast cancer screening (Harcourt et al., 2014;Lee et al., 2020), cervical cancer screening (Brzoska et al., 2020) and hepatitis B screening (Li et al., 2012). Following the conceptualisation of the constructs of the behavioural model of health What is known about the topic?
• The burden of hepatitis B is high in Ghana, yet testing uptake remains sub-optimal.
• Evidence of health-related factors influencing hepatitis B testing in Ghana has been previously documented but not individual level factors.
• Hepatitis B-related stigma and knowledge are important determinants of testing.

What this paper adds?
• This study adds to the limited number of quantitative studies on the correlates of hepatitis B testing in Africa.
• Individual level factors influencing hepatitis B testing uptake in Ghana is documented using the behavioural model of health service utilisation as a guide.
• The need for stigma reduction intervention is highlighted.
service utilisation for hepatitis B testing by Li et al. (2012), demographic characteristics of the participants such as age, gender, marital status, educational attainment, religion, place of residence and employment status were considered as predisposing factors. Hepatitis B knowledge and stigma endorsement were considered enabling and impeding factors, respectively (Li et al., 2012). Lastly, knowing someone with hepatitis B was described as a need factor (Li et al., 2012).

| Participants
Participants in the study were Ghanaians older than 18 years and reside in the Greater Accra and Northern regions of Ghana. Based on Krejcie and Morgan's (1970) formula for determining sample size, 971 participants (503 from the Greater Accra Region, 468 from the Northern Region) were recruited for the cross-sectional survey.
Greater Accra and the Northern regions were chosen because we wanted a good representation of people from the southern and northern part of the country.

| Measures
Hepatitis B testing was measured with a single item asking participants whether they have ever tested for hepatitis B. Answers were provided as either yes or no.
Hepatitis B knowledge was measured using an existing 15 item index previously used to measure hepatitis B knowledge in Ghana (Adjei et al., 2018). The index elicited questions on hepatitis B modes of transmission, diagnosis, prevention, treatment and follow-up care. Answers were provided with either yes, no and do not know.
Subsequently, the knowledge items were recoded into correct and incorrect responses. A higher score is indicative of a greater knowledge. All items can be seen in Table 2.
Hepatitis B stigma endorsement was measured using an adapted version of the 20-item Toronto Chinese Hepatitis B Stigma Index (Li et al., 2012). To ensure cultural appropriateness, we pretested the stigma index with 25 Ghanaian individuals, and the feedback obtained informed minor adaptation of some of the items. Specifically, we changed the word 'sweater' to 'clothes' and 'grocery shop' to 'supermarket'. Answers were provided on a 5-point Likert index ranging from 1 (strongly disagree) to 5 (strongly agree). A higher score is indicative of greater stigma endorsement (Li et al., 2012). The index showed a moderate to good internal consistency in this present study (Cronbach's Alpha value = 0.78). All items can be seen in Table 3.
Knowing someone with hepatitis B was measured by the question 'Do you know someone who is hepatitis B positive?'. Participants were asked to indicate either yes or no and further indicate their relationship with people they knew to have hepatitis B if they answered yes.
Demographic characteristics measured included gender, age, marital status, educational attainment, occupation, religion and place of residence.

| Procedure
Following approval of this study by the Korle-Bu Institutional Review Board (KBTH-IRB), we visited the study areas (i.e. Greater Accra and Northern region) between October 2018 and January 2019. Within these areas, we selected one district each through balloting. To arrive at the precise sample, we selected three electoral areas within each of the districts sampled. With the assistance of the assembly leaders in the electoral areas, we located roundabouts where a pen was spun, and the first house that faced the direction of the tip of the pen was used as the starting point for data collection (Grais et al., 2007). Participants were conveniently selected from the selected areas. The research assistants approached the potential participants in front of their homes mostly in the evening and weekends when many of the residents have returned from work. The purpose of the study was explained to the potential participants (i.e. those who met the inclusion criteria) and those who consented to participate were given a consent form to either sign or thumbprint. Overall, 62% of the participants were able to complete the questionnaire without any support. The research assistants assisted the remaining 38%. None of the participants received any form of compensation for taking part in the study. The response rate was 95%. On the average, participants took 20 minutes to complete the questionnaire.

| Data analyses
SPSS version 23.0 was used for the analyses. During data cleaning, retrieved questionnaires were checked for completeness and those found to have greater than 10% missing responses were excluded from the analyses. In the analyses, we first generated descriptive statistics (percentages, frequencies, means, standard deviations to describe the background of the participants). We then examined the responses per item of the questionnaire regarding hepatitis B knowledge and stigma endorsement. The 5-point Likert stigma index was transformed into 3-point index. These include disagree (i.e. combination of strongly disagree and disagree), agree (i.e., combination of strongly agree and agree) and neutral (neither agree nor disagree). Third, we used chisquare test for univariate analyses to examine the association between the categorical demographic variables and hepatitis B testing.
Fourth, we included the demographic variables that were found to be significantly related to testing behaviour in the chi-square tests in the first binary logistic regression model (i.e. marital status and educational attainment). The second binary logistic regression model (Model 2) then consisted of the predictors of interest (i.e. knowledge, stigma endorsement and knowing someone with hepatitis B) complemented with the demographic characteristics considered in Model 1. The level of statistical significance was set at p < 0.05. The odds ratio and 95% confidence interval were used to determine factors that were significantly associated with hepatitis B testing.

| Participant's characteristics
In total, 971 participants (i.e. 503 from the Greater Accra Region; 468 from the Northern Region) took part in the cross-sectional survey. Of these 971, 47.1% were male and 52.9% were female. About three-quarters (78.8%) had at least a secondary education. Ages ranged from 18 to 51 years (M = 30.52, SD = 8.10). Table 1 provides sample characteristics in details.

| Psychosocial correlates of hepatitis B testing
In addition to the univariate analyses (

| DISCUSS ION
This study investigated knowledge, stigma endorsement and knowing someone with hepatitis B as correlates of hepatitis B testing among people in the Greater Accra and Northern regions of Ghana.
The findings indicate that having more knowledge about hepatitis B and knowing someone with hepatitis B (i.e. parent, sibling and/or friend) were positively associated with hepatitis B testing.
Additionally, more stigma endorsement was negatively related to hepatitis B testing.
In this study, knowing someone with hepatitis B was the strongest determinant of testing. This finding confirms a previous report in Zambia where close contacts of PWHB opted for testing after learning about a family member having hepatitis B (Franklin et al., 2018). In addition, a study that examined barriers to, and factors predicting, hepatitis B screening among Asian individuals in Michigan, the USA, identified knowing someone with hepatitis B as the only predictor for screening (Cheng et al., 2017). A possible reason for the higher testing behaviour of participants without a formal education compared to their counterparts is that the majority of participants with no formal education in this study knew someone who had hepatitis B. Knowing someone with hepatitis B improves hepatitis B knowledge (Jin et al. 2022) and clarifies misconceptions and tends to minimise stigmatising reactions (Cheng et al., 2017). In this TA B L E 5 Psychosocial correlates of hepatitis B testing is a function of their risk perception: people who feel they are at risk are more likely to engage in testing (Earnshaw et al., 2012). We believe that participants who were close to someone with hepatitis B perceived greater risk and thus more likely to test. The finding also suggests that openness about having hepatitis B can both reduce stigma and encourage more testing, which subsequently leads to new diagnoses (WHO, 2017b).
In our study, we also found a positive association between hepatitis B knowledge and hepatitis B testing. The finding corroborates previous studies conducted in Canada (Li et al., 2012) and the United States (Calderon et al., 2014) where more knowledge about hepatitis B was related to higher testing uptake. For example, in a clustered-randomised trial that involved Korean church members in Los Angeles, participants with improved knowledge on liver cancer and hepatitis B testing were nearly five times more likely to get tested for hepatitis B (Bastani et al., 2015). In our study, most participants demonstrated fair knowledge about hepatitis B. More than three-quarters of the participants inaccurately indicated that hepatitis B can be transmitted through sweat. There is no evidence that hepatitis B transmission can be transmitted through sweat (Schillie et al., 2018). This misconception has previously been observed in Ghana (Adjei et al., 2018(Adjei et al., , 2019 and we believe that the confusion might be the result of earlier hepatitis B awareness campaigns in Ghana that focused on bodily fluids in a more general sense as a means of hepatitis B transmission. We further found that higher hepatitis B stigma endorsement was associated with less testing. The negative association between stigma endorsement and testing found is consistent with findings from the US, Canada, the Netherlands and Zambia (Franklin et al., 2018;Hamdiui et al., 2018;Hara et al., 2018;Li et al., 2012;Sriphanlop et al., 2014). This is also as expected, par-  (Adjei et al., 2017).

| Theoretical and practical implications
This study has some important theoretical and practical implications.
In terms of theory, this study adds to the limited number of quantitative studies on the correlates of hepatitis B testing in Africa. In the context of our theoretical model, namely the behavioural model of health service utilisation, it affirms knowledge as an enabling factor, stigma as an impeding factor and knowing someone with hepatitis B as a need factor that influences hepatitis B testing in the Ghanaian context. In terms of practice, based on our finding that stigma endorsement is negatively related to testing, we recommend stigma reduction interventions in Ghana. This is particularly important also in light of our finding that knowing someone with hepatitis B is positively related to testing as stigma may hinder disclosure. There is therefore also a need to create safe and non-judgmental contexts for PWHB to disclose if they want to. Importantly, disclosure should be preceded by hepatitis B education particularly for family members so that they can better understand the modes of hepatitis B transmission as well as prevention methods (i.e. vaccination) to avoid stigmatisation following disclosure of hepatitis status.

| Limitation of the study
Our study has some limitations. First, the use of the cross-sectional study design limits the possibility of establishing causal relationships. Second, we acknowledge the possibility of gambling in our participants' response to the knowledge items. The extent of gambling was however reduced by including the 'do not know' option.
Third, given that the total variance explained by our variables of interest on testing was relatively low, that is 21.0% using Cox and Snell R 2 and 28.0% using Nagelkerke R 2 , we recommend that future research further investigate other possible correlates of testing such access to testing (e.g. distance to testing site), social norms for testing and self-efficacy. Accordingly, we recognise that the operationalisation of the behavioural model of health service utilisation by our study is limited in scope given that there is other possible predisposing, enabling, impeding and need factors that were not examined. Finally, the convenience sampling technique imposes some limitations on the study's findings as it does not ensure randomisation, thereby limiting the possibility of generalising the results to the entire regions of Ghana.

| CON CLUS IONS
This study demonstrates that knowing someone with hepatitis B increases the likelihood of testing and this points to the need to create safe and non-judgmental contexts for PWHB to disclose if they want to. Also, given that higher knowledge about hepatitis B increases testing and hepatitis B stigma endorsement impedes testing, interventions that aim to increase knowledge and reduce hepatitis B stigma should be included in efforts to encourage testing in Ghana.

AUTH O R CO NTR I B UTI O N S
CAA, SS, RR and FN was involved in the conceptualization of the study. Data analyses and interpretation and the writing of the manuscript were done by CAA, FB, SS, RR and FN.

ACK N OWLED G EM ENT
The authors acknowledge the support of the Ghana Education Trust Fund (GETFUND) towards the first author's PhD programme. The authors also appreciate the contribution of the study participants.

E TH I C A L A PPROVA L
Ethical clearance was obtained from Institutional Review Board of Korle-Bu Teaching Hospital (Approval number KBTH-IRB 00092/2016). Permission was sought from the management of the data collection sites, and informed consent (written) was obtained from the participants.

CO N FLI C T O F I NTE R E S T
The authors declare no conflict of interest in this study.

DATA AVA I L A B I L I T Y S TAT E M E N T
All data are with the authors and available for sharing on request.